Name :

ACCOUNT CLOSURE REQUEST FORM

Date: D D M M Y Y Y Y

Please Note: (i) All accounts linked to the above account such as EEFC/FCY accounts for Current Accounts; Employee Reimbursement Account(ERA), Deposits and Junior a ccounts for Savings Accounts lso be closed., DEMAT and DMF Accounts will a

(ii) If the above account has a linked DEMAT/DMF account, please ensure that all holdings in the DEMAT/DMF account are zeroised before applying for account closure.

(iii) For NR accounts: In case of closure of a Term Deposits, the indicated deposit will be pre-liquidated.

I/We understand, agree and acknowledge that Citibank shall act solely on the basis of my/our instructions without any responsibility and liability upon the Bank. I/We further declare that I/We have already destroyed all cheque leaves and related card pertaining to above account.

CUSTOMER SIGNATURE (To be signed by all account-holders):

stSignature (1 Account Holder) ndSignature (2 Account Holder) rdSignature (3 Account Holder)

*Cannot be made to third-party accounts

Line 1 :

Line 2 :

City :

State : Country :

c By Demand Draft

Purpose of closure :

Branch :Account Number :

ACCOUNT DETAILS

DESIRED MODE OF RECEIPT* OF THE BALANCE AMOUNT (Please fill in the details for any of the options given below, as applicable, and strike out the rest)

c To another bank account by electronic transfer/Foreign Currency Telegraphic Transfer

Branch/City :Bank Name :

Name of account holder :

City :Citibank Account :

c To another Citibank account in India

Name of account holder :

Other bank account no.Reconfirm Account No.

: :

Account Type : # c Current Account c Savings Account (Resident) c NRE c NRO c FCNR

#Company accounts should be accompanied by a Board Resolution.

IFSC/SWIFT Code :

RECIPIENT ADDRESS DETAILS(Required only for Foreign Currency Telegraphic Transfers or Demand Drafts to be dispatched to “Other Address”. Please strike out this section if not applicable)

Currency : USD EURO GBP SGD CAD AUD c� c� �c� c� c� c� (This is applicable only for NRE accounts and FCNR deposits for Foreign currency telegraphic transfers or demand drafts. All other transfers will be in INR.)

c Mailing c Non-Mailing c Other AddressAddress for dispatch :

PIN/ZIP : Contact Number :Country Code Area Code

Signature verified by : Emp. ID: _____________Signature: __________________Name:________________________

ID Number: _________________ID Type:__________________________

Instruction received by : c In Personc Mail/Representative

c Yes c NoComplete set of originals received :

FOR BANK USE ONLY

Signature: __________________ Emp. ID: _____________Name:________________________(2)

Customer met in person by : Signature: __________________ Emp. ID: _____________Name:________________________(1)

Account Type : c Savings Account c Current AccountAccount Category

c NRE c NRO c Resident:

CV

/BA

N/A

CF/

Ver

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